Understanding

Abnormal Behavior
Chapter Seventeen

Therapeutic Interventions
Therapeutic Interventions
 Biology-based approaches
 Individual psychotherapy:
 Insight approaches
 Action approaches

 Group approaches:
 Group therapy
 Family therapy
 Couples therapy
Biology-Based Treatment
 Biological/somatic techniques use physical means to
alter the patient’s physiological and psychological
state
 Goes back to ancient times (trephining [boring a hole
in the heads of mentally ill patients to allow demons
to escape], bleeding and purging)
 Modern techniques:
 Electroconvulsive therapy
 Psychosurgery
 Psychopharmacology
Biology-Based Treatment (cont’d)
 Electroconvulsive therapy (ECT): The application of
electric voltage to the brain to induce convulsions
 Application of electric voltage to the brain to induce
convulsions
 Particularly useful for severe depression
 Patient is first given a muscle relaxant, then 65-140
volts of electricity are applied causing convulsions
and coma.
 Confusion and memory loss occurs for events
immediately before and after the ECT
Biology-Based Treatment (cont’d)
 Use of ECT declined in 1960’s-1970’s
because:
 Concerns about permanent brain damage
 Fracture/dislocation of bones
 Beneficial effects not long-term
 Abuses and side effects
 Advances in medication diminished the need
for ECT
 Not sure why it works.
Biology-Based Treatment (cont’d)
 Psychosurgery: Brain surgery performed to
correct severe mental disorders
 Prefrontal lobotomy
 Transorbital lobotomy
 Lobectomy
 Cauterization
Biology-Based Treatment (cont’d)
 Criticisms of psychosurgery:
 Patient improvement/lack of improvement is
independent of psychosurgical treatment
 Serious negative and irreversible side effects,
e.g., impaired cognitive and intellectual
functioning, listlessness, uninhibited impulsive
behavior, death
 Continuing seizures for some
 Humanitarian grounds: Psychosurgery always
produces permanent brain damage
Biology-Based Treatment (cont’d)
 Psychopharmacology: Study of the effects of
drugs on the mind and on behavior
 Advantages (reducing institutionalization) and
disadvantages (e.g., addiction and abuse;
gender bias, side effects)
 Four major categories:
 Antianxiety (minor tranquilizers)
 Antipsychotic (major tranquilizers)
 Antidepressant (MAOIs, tricyclics, SSRIs)
 Antimanic (lithium)
Table 17.1: Drugs Most Commonly Used in Drug Therapy
Barbiturates
 Barbiturates: highly addictive sedatives that have a
calming effect and were used before the 1950s.
 Result in tolerance
 Overdose can be deadly
 Withdrawal occurs with abrupt discontinuance
 Even appropriate doses can cause muscular
incoordination and mental confusion
 Were replaced by
Antianxiety Drugs (minor
tranquilizers)
 During the 1940s and 50s, the propanediols
and benzodiazepines became preferred
 Can be addictive and can cause withdrawal
symptoms, but are safer than the barbiturates
 Must be carefully monitored to prevent
overuse and overreliance
Antipsychotic Drugs (Major
Tranquilizers)
 Thorazine was developed as a sedative in the 1950 and had the
side effect of reducing psychotic symptoms.
 Drugs such as Thorazine, Stelazine, Prolixin and others
increase social interaction and self-management, and decrease
agitation for psychotic patients.
 Do not always reduce anxiety
 May lead to psychomotor symptoms (including tardive
dyskinesia), sensitivity to light, dry mouth, drowsiness or
liver disease.
 Do not lead to social recovery and patients must keep taking
them to prevent resurgence of symptoms
Antidepressant Drugs
 Discovered accidentally in the 1950s.
 Iponiazid (antitubercolosis medication) made people happier
and more optimistic
 Three classes of antidepressants
 MAOIs: Monoamineoxiydase Inhibitors – work by inhibiting
monoamineoxydase (an enzyme that breaks down
dopamine, norepinephrine and serotonin). Short-acting but
can produce toxic effects.
 Tricyclics: work like MAOIs but with fewer side effects
 SSRIs: work by inhibiting reuptake of serotonin (Prozac,
Zoloft). Fewer side effects and less likely to lead to
overdose than tricyclics. Associated with jitteriness and
stomach irritation.
Antimanic Drugs
 Lithium: mood-controlling (anti-manic) drug that controls about
70-80% of bipolar disorders
 Little is known about how it works.
 May limit availability of serotonin and norepinephrine…
however, it also decreases depression, which is inconsistent
with this effect
 Lithium is administered as a salt and appears to have no known
physiological function.
 Lithium is largely preventive and must be taken before
symptoms begin.
 It is extremely difficult to determine an effective yet non-toxic
dose.
Biology-Based Treatment (cont’d)
 Psychopharmacological considerations:
 Which medication to use with which kind of patient
under which circumstances
 Increases effectiveness of other types of treatment
 Medications reduce active symptoms and
hospitalizations, but do not cure mental disorders
 Women receive twice as many anti-anxiety
prescriptions, and 73% of all psychiatric prescriptions,
although they make up half of all clients seen by
psychiatrists.
 Not effective with passive symptoms and do not
improve living skills
 Lack of compliance is a problem
Psychotherapy
 Psychotherapy: Systematic application, by a
professional therapist, of techniques derived
from psychological principles, for the purpose
of helping psychologically troubled people
 Common therapeutic factors:
 Development of a therapeutic alliance
 Opportunity for catharsis
 Acquisition and practice of new behaviors
 Clients’ positive expectancies
Psychotherapy (cont’d)
 Korchin’s characteristics of psychotherapy:
 A chance for the client to relearn
 Help generating the development of new,
emotionally important experiences
 Therapeutic relationship
 Clients in psychotherapy have certain
motivations and expectations
Psychotherapy’s Goals:
 Change maladaptive behavior
 Minimize or eliminate environmental
conditions that may be causing or maintaining
such behavior
 Improveinterpersonal (and other) skills
 Resolve disabling conflicts among motives
 Modify dysfunctional beliefs
 Reduce or remove distress
 Foster a clear sense of identity
Why do people seek therapy?
 Sudden and highly stressful situations
 Referred by a physician for “physical” symptoms
 Referred by a spouse or attorney
 Chronic unhappiness and an inability to feel confident
and secure
 Vague dissatisfaction with self/life
 Intolerable mental states
Psychodynamic Therapies
 2 basic forms:
 Classical psychoanalysis
 Psychoanalytically oriented therapy

 Five basic techniques:

 Free association
 Dream analysis
 Analysis of resistance
 Analysis of transference
 Interpretation
Insight-Oriented Approaches to
Individual Psychotherapy
 Psychoanalysis: Freud: People are born with
instinctual drives that constantly seek to
discharge/express themselves
 As personality structure develops, conflicts
occur among the id, ego, and superego
 Unresolved conflicts resurface in adulthood
 Psychoanalysis seeks to overcome defenses
(repressed unacceptable thoughts/impulses)
Insight-Oriented Approaches to Individual
Psychotherapy (cont’d) Psychodynamic Therapy since
Freud
 Interpersonal Therapy
 Harry Stack Sullivan
 Examine all of a client’s relationships
 We are likely to react in stereotypical ways
with others, reflecting early learning
experiences
 Object Relations Therapy
 Focus is on interactions with (real and
imagined) other people
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Modern psychodynamic therapy (cont’d):
 Therapists are more active in the sessions,
restrict the number of sessions with a client,
put more emphasis on current than past
factors, and use client-centered techniques
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Effectiveness of psychoanalysis:
 Criticisms:
 Limited selection of clients (young, white, highly
educated)
 Difficulty with operational definitions (e.g.,
unconscious, libido) makes it difficult to test the
theory
 Symptom substitution
Humanistic-Existential Therapies
 See psychological problems as stemming from
alienation, depersonalization, loneliness, lack of
meaning and unfulfillment.
 Stress freedom of choice and personal responsibility,
as well as expanding the client’s awareness
 Client (person)-centered therapy
 Existential therapy
 Gestalt therapy
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Existential analysis: One’s experience/
involvement in the world as a consciousness/
self-consciousness being
 The inability to accept death/nonbeing restricts
self-actualization
 Existential crisis
 Philosophical and difficult to test
Insight-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Gestalt therapy: Person’s total experience is
important and should not be fragmented or
separated
 Here and now
 Dream analysis
 Statements to act out emotions, exaggerate
feelings to gain greater awareness, role-play
Table 17.2: A Systematic Desensitization Fear Hierarchy
for a Client with a Fear of Flying
Action-Oriented (Behavioral) Approaches
to Individual Psychotherapy
 Classical conditioning techniques:
 Systematic desensitization is used for anxiety.
 Relaxation, fear hierarchy, and combination of
relaxation and imagined scenes from fear
hierarchy
 Flooding and implosion to extinguish fear:
 Client is placed in real-life anxiety-provoking
situation at full intensity (flooding)
 Client imagines the anxiety-provoking situation at
full intensity (implosion)
Action-Oriented (Behavioral) Approaches
to Individual Psychotherapy (cont’d)
 Classical conditioning techniques:
 Aversive conditioning pairs undesirable
behavior with an unpleasant stimulus to
suppress the undesirable behavior.
Action-Oriented (Behavioral)
Approaches to Individual
Psychotherapy (cont’d)
 Operant conditioning techniques:
 Token economy: Treatment program that
rewards patients with tokens for appropriate
behaviors; tokens may be exchanged for such
things as hospital privileges, food, etc.
 Punishment: Used to treat children with autism
and schizophrenia when less drastic methods
don’t work
 Observational learning techniques (modeling):
Acquisition of new behaviors by watching
them being performed
Action-Oriented (Behavioral) Approaches
to Individual Psychotherapy (cont’d)
 Cognitive-behavioral therapy: Based on the belief that
psychopathology stems from irrational, faulty,
negative, and distorted thinking or self-statements
 Common elements: Cognitive restructuring, skills
training, problem solving
 No exclusive set of techniques exists
 Therapy often includes “experiments” which involve
changing thoughts and behaviors and evaluating
results.
 Rational-emotive therapy (RET)/Albert Ellis
 Cognitive triad (Aaron Beck)
 Stress inoculation therapy
Rational Emotive Behavior
Therapy
 Albert Ellis (beginning in 1958)
 Attempts to change a client’s maladaptive thought
process, which determine emotions and behavior
 Unrealistic beliefs and perfectionistic values cause
people to behavior irrationally and undervalue
themselves
 Task of therapy is to restructure the person’s belief
system and self-evaluation.
Stress Inoculation Therapy
 Self-instructional training focused on altering self-
statements an individual normally makes in stress-
producing situations.
 Three stages:
 Explore beliefs and attitudes about problem situations
(cognitive preparation)
 Learning and practicing adaptive self-statements (skill
acquisition and rehearsal)
 Applying principles in actual situations (application and
practice)
Beck’s Cognitive Therapies
 Psychological problems result from illogical thinking
about self, world and future.
 Therapy consists of identifying connections between
thoughts and emotions, and learning to challenge
automatic thoughts.
 Therapy DOES NOT involve a debate about the
client’s irrational beliefs, but rather, teaching the
client to identify and test false beliefs.
Action-Oriented Approaches to
Individual Psychotherapy (cont’d)
 Health psychology: Integration of behavioral
and biomedical sciences acknowledging that
psychological factors are often related to the
cause and treatment of physical illnesses
 Biofeedback: Patient receives information
(feedback) regarding autonomic functions and
is rewarded for influencing those functions in a
desired direction
 Type-A behavior (Meyer Friedman)
Evaluating Individual
Psychotherapy
 Hans Eysenck: There is no evidence that
psychotherapy facilitates recovery.
 100s of studies prove that Eysenck was wrong; the
more psychotherapy people receive, the more they
improve and the fewer symptoms they report.
 Persons: Contemporary outcome studies did not
accurately represent psychotherapy, which is difficult
to measure
 Efficacy studies: Brief, well-controlled, well-designed
research investigations into the outcome of a
treatment
Evaluating Individual
Psychotherapy (cont’d)
 Effectiveness studies: Examine the outcome
of treatment as it is delivered in real life
 Effectiveness studies demonstrate greater
patient improvement than efficacy studies and
improvements across different kinds of
therapies
Figure 17.1: Predictions of the Theoretical
Orientations of the Future
Evaluating Individual
Psychotherapy (cont’d)
 Meta-analysis and effect size:
 Meta-analyses analyze a large number of
different studies at one time by looking at
effect size, or treatment-produced change
 Meta-analyses support a conclusion that
psychotherapy is effective
 Meta-analyses:
 Empirically supported treatments (ESTs):
Clearly specified psychological treatments
shown to be efficacious in controlled research
with a delineated population
Figure 17.2: Effect Sizes for
Psychotherapy, Placebo, and No-
Treatment Groups
Group, Family, and Couples
Therapy
 Simultaneous treatment of 2 or more clients and may
involve more than one therapist
 Members may be related or may be strangers, but
they share various characteristics
 Therapists can provide more mental health service to
the community
 The cost to each person is reduced
 Many psychological difficulties involve relationships
with others and are best treated in a group rather than
individually
Group, Family, and Couples
Therapy (cont’d)
 Features of successful groups:
 Clients are involved in social situations and
see how their behavior affects others
 Therapist see how clients respond in real-life
social and interpersonal contexts
 Clients develop communication skills, social
skills, and insights
 Less isolated and fearful about problems
 Groups can provide members with social/
emotional support
Group, Family, and Couples
Therapy (cont’d)
 Disadvantages of group therapy:
 Little attention to individual problems
 Clients may not want to share problems with a
group
 Loss of intimacy with therapist
 Group pressures may be too strong or group
values too deviant
 Leaderless groups may not be able to
recognize or treat people with psychotic or
suicidal impulses
Group, Family, and Couples
Therapy (cont’d)
 Family therapy: Group therapy that seeks to modify
relationships within a family to achieve harmony
 Based on three assumptions:
 It is logical and economical to treat people together who
exist and operate in a system of relationships
 The problems of the “identified patient” are only symptoms;
the family itself is the client.
 The task of the therapist is to modify relationships within the
family system.
 Two Aprroaches:
 Communications approach: Assumes that family problems
arise from communication difficulties
 Systems approach: Emphasizes the interlocking roles of
family members, assuming it is the family system that
contributes to pathological behavior in the family
Group, Family, and Couples
Therapy (cont’d)
 Family therapy:
 Couples therapy: Treatment aimed at helping
couples understand and clarify their
communications, role relationships, unfulfilled
needs, and unrealistic/unmet expectations
Systematic Integration and
Eclecticism
 Therapeutic eclecticism: The “process of
selecting concept, methods, and strategies
from a variety of current theories which work”
 Integrative approach: No one theory/approach
is sufficient to explain and treat the complex
human organism
 Goal: Integrate the therapies that work best
with specific clients who show specific
problems under specific conditions
Culturally Diverse Populations and
Psychotherapy
 Western psychology and mental health concepts are
based on an assumption that they are universal and
the human condition is governed by universal
principles.
 Surgeon General’s Report on Mental Health:
 It is dangerous to use European American standards to
judge normality and abnormality and may result in
denying appropriate treatment to minority groups.
Culturally Diverse Populations and
Psychotherapy (cont’d)
 African Americans:
 Prevalence of mental disorders is higher than
that of the general population
 Underrepresented in privately financed care,
overrepresented in public care
 Poverty rate is 3 times that of whites
 Many barriers to effective treatment: Historical
hostility, therapists’ bias and lack of
knowledge of African American cultural
values
Culturally Diverse Populations and
Psychotherapy (cont’d)
 Asian Americans/Pacific Islanders:
 Underutilize mental health facilities possibly because of
low rates of mental disorders, discriminatory mental
health practices, and/or cultural values
 Many problems are hidden but there are problems
associated with past traumas and current resettlement
problems and racism
 High levels of PTSD and depression
 Barriers to effective therapy: Process and goals of
therapy may be antagonistic to cultural values
Culturally Diverse Populations and
Psychotherapy (cont’d)
 Latino/Hispanic Americans:
 Value family unity and loyalty to entire
“extended” family
 Subject to poverty and prejudice
 Therapists need to understand the
psychosocial, economic, and political needs of
Hispanic clients and should be bilingual/
bicultural.
 Understand issues of patriarchal system
Culturally Diverse Populations and
Psychotherapy (cont’d)
 Native Americans:
 Heterogeneous group: 550 tribes
 High poverty, high rates of death among
children, less education, high unemployment
 Value cooperation rather than independence,
present rather than future, harmony with
nature
 High rates of suicide and substance abuse
 U.S. oppression has caused disrupted
families, poverty, prejudice, and discrimination
Community Psychology
 Community psychology:
 Takes into account the influence of
environmental factors
 Encourages the use of community resources
and agencies to eliminate conditions that
produce psychological problems
 Promotes well-being and prevention of mental
disturbance
Figure 17.3: Use of Mental Health Services
Among Individuals with Mental or
Addictive Disorders
 Community Psychology (cont’d)
 Managed health care: Changes are needed in the
mental health system to make services accessible,
available, and affordable
 HMOs: Turn to managed-care companies to
administer benefit plans
 Emphasize short-term treatment
 Use of MAs and MSs instead of MDs, PhDs, and
PsyDs
 Emphasize accountability and quality assurance
Community Psychology (cont’d)
 Concerns about managed care:
 Quality/extent of services sacrificed for cost
 APA endorses training clinical psychologists to
prescribe medications
 “Manualized” treatment
 Computer-generated psychotherapy
Community Psychology (cont’d)
 Prevention of psychopathology:
 Primary prevention: Effort to lower the
incidence of new cases of behavioral
disorders by strengthening or adding to
resources that promote mental health and
eliminating community characteristics that
threaten mental health
Community Psychology (cont’d)
 Prevention of psychopathology:
 Secondary prevention: Attempt to shorten the
duration of mental disorders and reduce their
impact
 Tertiary prevention: Facilitates the
readjustment of individuals to community life
after hospital treatment for mental disorders